ENS 43337
ENS Event | |
|---|---|
04:00 Jan 16, 2007 | |
| Title | Agreement State Report - Dose to Patient |
| Event Description | On March 9, 2007, a consultant for the Aroostook Medical Center (TAMC) notified the TAMC Nuclear Medicine Department a medical event may have taken place on January 16, 2007.
The licensee investigated the report and found that a 4 millicurie dose of I-131 was given to a patient on the date in question as a whole body scan. However, the licensee determined that the ordering physician actually wanted an I-131 uptake and scan of 150 microCuries of I-131. Upon further investigation, the licensee determined that the scheduling person (who does not have a background in Nuclear Medicine) ordered the I-131 whole body scan. The licensee initiated a report of medical event and contacted the patient's physician. The licensee calculated the whole body effective dose equivalent and the dose to the thyroid from the excess dose of I-131. The dose to the patients thyroid gland was calculated to be approximately 14000 rem and the whole body effective dose equivalent was calculated to be approximately 6.4 rem. The licensee determined that if the proper amount of I-131 had been administered, the doses would have been 525 rem and 0.24 rem respectively. A doctor at the licensee's facility determined that the dose given to the patient on March 16, 2007 will not have any effects on the patient. To prevent further events as this one, the Hospital and Radiation Safety Officer has decided that any further requests for I-131 procedures will be verified directly with the referring physician." There are now policies in effect to prevent this situation from happening again. The state of Maine entered this report into NMED as number ME070016.
This event (EN43337) has been reviewed and determined to be a reportable medical event.
Nature and Probable Consequences: The licensee reported that a patient undergoing treatment for malignant melanoma and presenting an asymmetric thyroid, received a Tc-99m scan and ultrasound was subsequently scheduled for a whole body scan utilizing I-131 to further diagnose the problem. The scan was ordered and the CNMT questioned the whole body scan and asked the physicians office to clarify what they wanted: an uptake or a whole body scan. The oncologist's secretary confirmed a whole body scan. On January 16, 2007 the patient received 0.1458 MBq (3.94 mCi) of I-131. On March 6, 2007 during a follow-up visit with an endocrinologist it was recognized that the wrong scan was performed. Upon investigation by the licensee and the licensee's consultant it was discovered that a medical event had indeed occurred. The administration (0.1458 MBq (3.94 mCi) vs the intended dosage of 5.55 MBq (150 microCuries)) of [I-131] resulted in a thyroid dose of 51.22 Gy (5,122 rad) and a whole body dose of 15.37 Sv (153.66 Rem) using NUREG-CR-6345 methodology. (if ICRP#30 or FGR #11 methodology used, results are 70 Gy (7000 Rad) for a thyroid dose and 21.25 Sv (212.5 Rem) dose to the whole body. The patient and referring physician were notified of the error. No negative health effects from this administration are expected. On March 28, 2007, the licensee sent a letter to the State confirming that a medical event had occurred. Cause(s): This medical event was caused by human error. The licensee failed to verify the prescribed dosage for a specific patient directly with the referring physician and a written directive was not filled out. Actions Taken to Prevent Recurrence: Licensee - Corrective actions taken by the licensee included revising procedures to improve communication with referring physicians to include the CNMT speaking directly with the referring physician or Authorized User to confirm test to be done. Also, written directives will be done for all administrations of I-131 in quantities greater than 30 microCuries. State Agency - The State Radiation Control Program (RCP) performed an on site investigation on May 24, 2007 and requested corrective action by the licensee. The RCP issued a Notice of Violation on November 1, 2007 and awaits the licensee's response. The RCP did initially review and accept the licensee's proposed corrective actions during the on-site investigation. This event is closed for the purpose of this report. A "Medical Event" may indicate potential problems in a medical facility's use of radioactive materials. It does not necessarily result in harm to the patient. |
| Where | |
|---|---|
| Aroostook Medical Center Presque Isle, Maine (NRC Region 1) | |
| License number: | 03803-02 |
| Organization: | Maine Radiation Control Program |
| Reporting | |
| Agreement State | |
| Time - Person (Reporting Time:+2555 h106.458 days <br />15.208 weeks <br />3.5 months <br />) | |
| Opened: | Shawn Seeley 14:00 May 2, 2007 |
| NRC Officer: | Pete Snyder |
| Last Updated: | Nov 2, 2007 |
| 43337 - NRC Website | |
Aroostook Medical Center with Agreement State | |
WEEKMONTHYEARENS 433372007-01-16T04:00:00016 January 2007 04:00:00
[Table view]Agreement State Agreement State Report - Dose to Patient 2007-01-16T04:00:00 | |